Constipation

Overview

Constipation is associated with difficult or painful passage of stools and/or delayed frequency of stools that lasts at least 2 weeks. [Levy: 2016] [Varier: 2013] Normal stooling patterns change as children age. Newborns typically pass their initial stool (meconium) in the first 2 days. The pattern in infants can range from multiple stools daily to 1 stool every 10-14 days; the latter is more common in breastfed infants. During toilet training, children may have more episodes of constipation as they learn to attend to the body’s signals. For children ages 4 and older, 1 daily stool is typical. Stool consistency is considered normal when the stools are soft and mushy or formed. About 85% of people have a hard stool (fecal ball) present in the rectum after waking up, which is not the same as being constipated. [Varier: 2013] Although constipation may have several etiologies, functional constipation, which involves no underlying medical condition, is the most common type experienced by children and is the focus of this resource.

Other Names & Coding

ICD-10 coding

K59.00, Unspecified

K59.01, Slow transit constipation

K59.03, Drug-induced constipation

K59.04, Chronic idiopathic constipation

K59.09, Other constipation

R15.1, Fecal smearing or soiling (encopresis)

F98.1, Encopresis not due to a substance or known physiological condition

ICD-10 for Constipation (icd10data.com) provides further coding details.

Prevalence

Worldwide, the prevalence of constipation in children is about 10%. [Avelar: 2020] Constipation is responsible for 3% of all primary care visits for children and 10-25% of pediatric gastroenterology visits. [Tabbers: 2014] Only 60% of children with functional constipation have resolution of symptoms 6-12 months after treatment, and 25% continue to experience constipation into adulthood. [Koppen: 2018] While constipation is frequently a chronic, long-term problem, much of its management can be done in the primary care setting.

Genetics

Numerous genetic syndromes are associated with an increased risk of childhood constipation. Genetic factors are also thought to play a role in functional constipation, but linkage studies, association studies, and direct gene sequencing have yet to find associated gene mutations.  [Peeters: 2011]

Prognosis

Most children with functional constipation require prolonged treatment. In one study, after intensive initial medical and behavioral treatment, 60% of children were treated successfully at 1 year of follow-up and 80% at 8 years. One-third of the children needing follow-up beyond puberty continued to have severe complaints of constipation. [van: 2003]

Practice Guidelines

Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA.
Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN.
J Pediatr Gastroenterol Nutr. 2014;58(2):258-74. PubMed abstract / Full Text

Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S.
Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.
Gastroenterology. 2016. PubMed abstract

Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M.
Functional Disorders: Children and Adolescents.
Gastroenterology. 2016. PubMed abstract

Roles of the Medical Home

The goals of constipation management by the medical home clinician include early recognition and effective management to prevent unnecessary emergency room visits and hospitalizations, as well as morbidity and mortality related to severe constipation. Successful therapy requires prevention and treatment of fecal impaction with oral laxatives or rectal therapies, increased dietary fiber, family education about withholding behaviors, and behavioral interventions.  [Nurko: 2014]

Clinical Assessment

Overview

Constipation can occur for several reasons:
  • Poor involuntary or voluntary neurologic control and muscle coordination in the GI tract, which can be due to chronic overstretching from retained or backed-up stool, surgical disruption, abnormal anatomy, and decreased neuroregulation and sensation
  • Dietary factors including inadequate fluid (especially water); inadequate fiber (found in whole grains, fruits, and vegetables); constipating foods (such as infant rice cereal, bananas, and cheese); lack of stimulating foods (e.g., prunes, apples, pear juice); and unstructured grazing (instead of eating regular meals, thus losing the peristaltic stimulus of a food bolus)
  • Emotional factors including anxiety over painful stools, withholding behaviors that develop after having painful/hard stools, toileting accidents or stressful training, anxiety about asking to use the bathroom, and difficulty relaxing while in the bathroom
  • Lifestyle factors including inadequate exercise and lack of access to unhurried toilet time after meals or when the rectum feels full
  • Intake of certain medications (antacids with calcium or aluminum, antidepressants, antihistamines, narcotics, some antihypertensives, anticonvulsants, and antipsychotics) or iron supplements (however, the iron fortification in infant formula is not considered a contributing factor). See Medications That Can Affect Colonic Function (IFFGD) for a more complete list.
Pain-Retention Cycle in Constipation: Retention of Stool>Stool accumulates in rectum>Stool becomes hard>pain
Withholding stool can lead to a pain-retention cycle that exacerbates constipation. Withholding stool can lead to bulky, hard stools as the intestine reabsorbs more water when the stool does not pass. Pain associated with constipation can lead to not wanting to pass the stool and more withholding. When a child does not pass stool regularly and stool builds up in the rectum, liquid stool may leak around the hard stool mass, and the child may develop decreased voluntary control over the anal sphincter resulting in accidents like encopresis (soiling of the underwear) and other complications.

Pearls & Alerts for Assessment

Red flags for organic disease

Consider further causes of constipation if there is delayed passage of meconium; onset <1 month of age; vomiting with abdominal pain or distension, or bilious vomiting; blood mixed into the stool; pain-causing night awakenings; weight loss; or abnormal neurologic findings (e.g., abnormal anal tone, absence of anal wink, sacral tuft of hair) or abnormal gastrointestinal tract findings (e.g., peri-anal fistula or tags, imperforate or anteriorly placed anus).

When to refer

Referral to a subspecialist is recommended only when there is concern for organic disease or when constipation persists despite appropriate therapy.

Causes of fecal incontinence

While fecal incontinence (including soiling and encopresis) usually is due to constipation, 20% of incontinent children actually have non-retentive fecal incontinence (defined as socially inappropriate loss of control of the bowels not caused by constipation or another medical condition). [Koppen: 2016]

Screening

No screening is recommended.

Presentations

Presentations may involve:
  • Straining in toddlers and older children, although in infants, straining and crying to pass normal, soft stool (known as dyschezia) is common and should improve once the infant has more muscle coordination
  • In toddlers and children, behaviors that reflect attempts to not pass stool, such as standing and/or crossing their legs while straining or hiding when they need to pass stool
  • Infrequent stools for the child’s age and/or very irregular patterns of stooling
  • Tearing/bleeding from the rectum (anal fissures, hematochezia)
  • Fecal soiling due to leakage around large, obstructing stool and decreased sensitivity and awareness of the presence of stool at the anus. Soiling (stool staining in the underwear) and encopresis (loss of full-size stool) are often used interchangeably and are both included in the term “fecal incontinence” used in current literature and guidelines.
  • Pebbly or bulky hard stools (can clog the toilet). See Bristol Stool Scale (below), types 1-2.
    Bristol Stool Form Scale (click for larger image)
    Bristol Stool Chart with images showing degrees of constipation
  • Withholding and/or accidents due to anxiety about painful stools
  • Onset of abdominal pain with meals, due to stimulation of the gastro-colic reflex resulting in cramping as peristalsis meets firm stool that is hard to move
  • Less commonly, vomiting or reflux

Diagnostic Criteria

According to Rome IV, diagnostic criteria for the Neonate/Toddler, diagnosis of functional constipation must include 1 month of at least 2 of the following in infants up to 4 years of age: [Benninga: 2016]
  • Two or fewer defecations per week
  • History of excessive stool retention
  • History of painful or hard bowel movements
  • History of large-diameter stools
  • Presence of a large fecal mass in the rectum
In toilet-trained children, the following additional criteria may be used:
  • At least 1 episode/week of incontinence after the acquisition of toileting skills
  • History of large-diameter stools that may obstruct the toilet
According to Rome IV, diagnostic criteria for the Child/Adolescent, diagnosis of functional constipation must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome: [Hyams: 2016]
  • Two or fewer defecations in the toilet per week in a child whose developmental age is at least 4 years
  • At least 1 episode of fecal incontinence* per week
  • History of retentive posturing (standing or sitting with legs crossed or straight and stiff to avoid passing stool, or hiding and becoming red in the face while straining to hold in stool) or excessive volitional stool retention
  • History of painful or hard bowel movements
  • Presence of a large fecal mass in the rectum
  • History of large diameter stools that can obstruct the toilet
After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.
*Of note, while constipation causes the majority of childhood fecal incontinence (including soiling and encopresis), 20% of incontinent children actually have non-retentive fecal incontinence (defined as socially inappropriate loss of control of the bowels not caused by constipation or another medical condition). [Koppen: 2016]

Differential Diagnosis

Differential diagnoses can include other non-organic/functional etiologies:
  • Normal stooling
  • Infant dyschezia
  • Normal early childhood developmental phase (typical for kids ages 16-24 months) – usually situational (fear of toilet training or school bathroom avoidance) Non-retentive fecal incontinence (defined as socially inappropriate loss of control of the bowels not caused by constipation or another medical condition). [Koppen: 2016]
  • Attention-deficit, autism spectrum disorder, or cognitive delays
  • Sexual abuse [Philips: 2015]
  • Colonic inertia or genetic predisposition
  • Low fiber or fluid diet
  • Inadequate nutrition
Differential Diagnosis of Constipation in Children (AAFP), Table 4, lists recommended diagnostic evaluation for possible differential diagnoses.

Medical Conditions Causing Condition

Medical conditions that may cause constipation (i.e., organic causes) include:
  • Hirschsprung disease
  • Spina bifida
  • Cerebral palsy
  • Autism
  • Hypothyroidism or electrolyte disturbances
  • Systemic disorders, including diabetes mellitus, celiac disease, cystic fibrosis, dermatomyositis, scleroderma, autoimmune conditions, panhypopituitarism
  • Multiple endocrine neoplasia type 2B
  • Developmental delays
  • Tube feeding
  • Anxiety (fear of using public restrooms, asking permission to go to the bathroom at school, etc.)
  • Inadequate intake of fluid and nutrition or excessive vomiting (not enough in, not enough out)
  • Drug, supplement, or toxin effect (e.g., analgesics, anticholinergics, antacids, psychotropics, iron, lead, botulinum)
  • Obstruction or pseudoobstruction
  • Irritable bowel syndrome
  • Specific dietary protein allergy (e.g., cow milk protein)
  • Anatomical malformations or masses of the intestinal tract
  • Spinal cord dysfunction, tethered cord, tumors of the spinal cord
  • Sensory integration disorder
    [Tabbers: 2014] [Philips: 2015]
Red Flags Suggesting an Organic Cause of Constipation in Children (AAFP), Table 3, presents clinical findings that may be suggestive of a diagnosis other than functional constipation.

History & Examination

Frequently, the medical home clinician can diagnose constipation based on history. The physical exam may provide supporting evidence, such as palpable stool in the abdomen or rectal vault, and lack of findings suggestive of a “surgical belly.” Labs and imaging usually are not needed to diagnose functional constipation

Current & Past Medical History

General questions:
  • Was there passage of meconium after 48 hours of birth?
  • Is there difficulty or delay in stooling that has been present at least 2 weeks?
  • What is the consistency and appearance of the stool? Communication about different stool consistencies can be made simpler using stool scales or by looking at samples or pictures that families bring to discuss. Check if there are hard, pebble-like, or fragmented stools.
  • Are any of the following present?
    • Infrequent stooling that is associated with pain
    • Is the pain associated with a sense of urgency to stool, and is the pain relieved with the passage of stool?
    • Sharp, cramping abdominal pain
      • Typical location is near the belly button or lower left or right side.
      • Typical timing is intermittent daytime pain, during or shortly after a meal (typically dinner), or with exercise.
    • Stool withholding or fear of passing stool
    • Stool leaking/fecal soiling (involuntary staining of the underpants, also known as encopresis) or stool accidents not appropriate for developmental age. [Hyams: 2016] Soiling is more commonly associated with constipation, whereas loss of full-size stool may be associated with functional non-retentive fecal incontinence (FNRFI). [Koppen: 2016] Fecal incontinence that occurs without evidence of stool retention or slowed colonic transit time, or is in conjunction with urinary incontinence, or is associated with stress or trauma in the child’s life, should trigger the clinician to consider a diagnosis of functional non-retentive fecal incontinence.
    • Toilet clogging (large, bulky stools)
    • Dyschezia
    • Sense of incomplete bowel movements/unable to fully empty
    • Early satiety/fills up fast, sense of bloating or nausea, prefers to snack rather than have a full meal
    • Change in eating patterns (volume/pace) associated with changes in bowel frequency
    • Irritability when no stool has passed recently
    • School absence related to constipation or abdominal pain
  • What is the toileting schedule or pattern? The Stool Diary Using Bristol Stool Form Scale (NIH) (PDF Document 147 KB) can help families record this information.
  • What is the timing and composition of meals, snacks, and fluid intake? A 3-day intake diary may be useful to review.
    • Is there excessive milk or juice intake?
    • Is there a pattern of eating small amounts throughout the day (grazing pattern of eating)?
  • Ask about frequency of exercise. For children with limited mobility, ask about time in standers or walkers.
  • Identify chronic illnesses and medical conditions, including prior procedures and surgeries. Obtain information about any prior GI studies or tests and any medical providers already consulted for this issue.
  • Identify all over-the-counter and prescription medications, fiber, and natural remedies used.

Physical Exam

Constipation is present if the history suggests constipation, and there is a palpable fecal mass on abdominal exam and/or a large amount of stool present on rectal exam. It is helpful to know that a stool ball may be present in 85% of children in the morning, so a fecal ball on rectal exam does not automatically require medical intervention.

General

Perform visual exam for fissures, hemorrhoids, fistula, tags, prolapse, or abnormal positioning and whether they are on or off the midline position. Although a routine rectal exam is not recommended to diagnose functional constipation, the exam may be needed to exclude or evaluate other conditions (e.g., Hirschsprung disease in infancy). 

Evaluate hydration status, pain status, ability to take oral fluids and medications, and mental status.

Growth Parameters

Evaluate growth curve for weight loss, short stature, or low weight for height/length or declining BMI. Failure to thrive may be an indication of Hirschsprung disease, impaction, or neurenteric problems. [Tabbers: 2014]

Skin

Check for atopic dermatitis.

HEENT/Oral

Check for aphthous ulcers, which can be indicative of inflammatory bowel disease.

Abdomen

Check for bowel sounds, distension, focal or diffuse tenderness, palpable fecal mass, or surgical scars.

Extremities/Musculoskeletal

Look for overt spinal anomalies, such as abnormal sacral dimple or sinus, hair patch, or pigmentation above the gluteal cleft. Check for clubbing or joint pain.

Neurologic Exam

Evaluate sphincter tone and anal wink; consider cremasteric response. Assess gross motor control to the lower portion of the body by visualizing gait and weight-bearing, for example, and assess for lower body sensation and deep tendon reflexes.

Testing

Labs and imaging studies are usually unnecessary in the outpatient setting. However, particularly if there are red flags, consider focused testing.

Laboratory Testing

When red flags are present, consider serum electrolytes, calcium, phosphorus, complete blood count, celiac panel, thyroid-stimulating hormone, urinalysis and culture, sedimentation rate and/or C-reactive protein, lead level, albumin, iron stores, or guaiac stool testing may be considered to evaluate for specific causes. Elevated fecal calprotectin (stool study) can indicate chronic inflammation.

Imaging

Abdominal X-ray (KUB) is not recommended as a routine test for constipation in children, nor to routinely confirm a successful “clean-out.” Incidental finding of stool on radiography is not independently diagnostic of constipation. A KUB does not indicate stool consistency. It may be considered to look for fecal impaction in children unwilling to have a rectal exam or when there is significant obesity impairing the abdominal exam. KUB can be considered to assess if there is a dosage issue or constipation with overflow when the patient has been undergoing treatment for constipation and then develops diarrhea.

Abdominal X-rays should be obtained if there is concern for bowel obstruction or perforation (2-views) or a foreign body (foreign body series).

In unusual cases, studies such as barium enemas, manography, endoscopy, GI biopsies, and emptying times may be useful diagnostic tools, but these are not routinely indicated and consultation with a pediatric gastroenterologist would be advised.

Un-prepped barium enema can be used to identify a transition zone, such as with Hirschsprung disease, when there is a gush of fluid or stool following a digital rectal exam or history of failing to pass meconium in a timely fashion. This is most useful diagnostically in children <2 years of age. The barium used can also help pass stool, therapeutically.

MRI of lumbosacral spine to evaluate for tethered cord (e.g., for history of motor neuron issues, findings of sacral lipoma or tuft). Spinal ultrasound may be performed as screening for newborns with abnormal sacral findings.

Not generally ordered by primary care clinicians, the following studies may be ordered by a pediatric gastroenterologist as further evaluation, if indicated:
  • Anorectal manometry can help identify increased rectal sensory threshold (i.e., difficulty sensing stool burden), paradoxical contraction of pelvic floor muscles and external anal sphincter, or failure of relaxation of the internal anal sphincter. This requires a cooperative child.
  • Colonic manometry can assess sensation and tone and may be used in the assessment of sensorimotor function.
  • Anal sphincter electromyography can be used to evaluate the activity of the external anal sphincter and puborectalis muscles. This can be used in biofeedback to support more efficient, effective passage of stool.
  • Colonic transit time (CTT) may assist in differentiating between fecal incontinence that is related to constipation (in which the transit time may be slower than normal) and functional non-retentive fecal incontinence, which is associated with normal CTT. CTT can be assessed via abdominal X-ray after swallowing a radio-opaque marker or by colonic transit scintigraphy. [Koppen: 2016]

Specialty Collaborations & Other Services

Pediatric Gastroenterology (see UT providers [4])

Refer for constipation that does not respond to treatment or for concerns of other organic gastrointestinal disease.

Colorectal Care Clinics (see UT providers [1])

Refer for abnormalities found on barium enemas, obstruction/pseudoobstruction, or anatomic abnormalities. Some locations offer a comprehensive/multidisciplinary colorectal center with surgery, urology, gastroenterology, gynecology, neurosurgery, cardiology, nursing, child life, social work, and/or nutrition.

Pediatric Neurosurgery (see UT providers [3])

Refer for suspected tethered cord or other spinal anomalies.

Treatment & Management

Pearls & Alerts for Treatment & Management

Most recommended medication for maintenance therapy

The most highly recommended medication for maintenance therapy for pediatric functional constipation is polyethylene glycol (PEG). Lactulose, milk of magnesia, mineral oil, and stimulant laxatives can be added or used as second-line therapies. [Tabbers: 2014] While current guidelines support use of lactulose over the other second-line therapies, a 2016 Cochrane review found it inferior to mineral oil (liquid paraffin) or milk of magnesia. [Gordon: 2016]

Maintenance therapy

Polyethylene glycol (PEG) and lactulose are considered the safest medications for daily maintenance therapy in children. [Tabbers: 2014] Maintenance therapy is generally recommended to be continued for at least 6 months and then gradually discontinued with monitoring of stools to make sure the tapering is tolerated. [Tabbers: 2014] Some experts advised maintenance therapy for up to 18 months. Early discontinuation of maintenance therapy by families or clinicians is a common reason for constipation to recur. Dosing guidance is in Pharmacy & Medications, below.

Clean-outs before maintenance therapy

Children with moderate to severe constipation typically need a “clean-out” prior to initiating maintenance therapy. The goal of a clean-out is to stimulate and soften bowel movements, not to obtain clear liquid stools needed to prep for a colonoscopy.

Thickeners and PEG

Starch- and xanthan gum-based thickeners are used to increase the density of fluids to reduce the risk of aspiration for children with swallowing dysfunction. Recent research suggests that interactions between starch-based thickeners and PEG may result in inconsistent thickening and thus reduce their effectiveness. To date, xanthan gum-based thickeners do not seem to be affected by PEG. [Carlisle: 2016]

Aspiration Risk

While constipation is generally treated the same way in children with neurological impairment (NI) as for children without neurological impairment, severe pneumonias have been linked to aspiration of polyethylene glycol and other oral laxatives in children with NI. [Romano: 2017]

Offsetting costs of diapers for older children

Diapers are a large health care expense. Generally, Medicaid will cover the cost of diapers for the incontinent child after age 3 through a home care company with a clinician’s prescription and letter of medical necessity. Less frequently, private payers can be convinced to do this.

How should common problems be managed differently in children with Constipation?

Over the Counter Medications

The cost of laxatives adds up quickly. If possible, select medications that the family’s insurance will cover; otherwise, suggest generics (store brands), coupons, or online shopping to compare prices.

Common Complaints

Children often indicate the area around their umbilicus when asked to locate their abdominal pain related to constipation. When appropriate, reassure parents that their child can continue to participate in activities and attend school despite having occasional abdominal pain.

Systems

Gastro-Intestinal & Bowel Function

Constipation management varies by age but generally includes optimizing dietary fiber and water intake and limiting constipating foods; improving toileting practices; ensuring adequate exercise and relaxation; and judicious use of laxative medications. Frequent follow-up in the primary care setting can be very helpful to ensure success. Refractory constipation may require guidance from a Pediatric Gastroenterologist and may entail additional interventions including biofeedback - see Non-Pharmacological Treatment of Functional Constipation in Children (PDF Document 62 KB), scheduled enemas, or surgical interventions. The following information explains developmental approaches to treatment of constipation, prevention, and complications. Medications (including fiber supplements) and complementary & alternative approaches are addressed in subsequent sections.

Educational resources for parents may include:
Infancy
A common time for infants to become constipated is during the introduction of solid foods and cereals to the diet. Infants may express more irritability or arch their back and cry when passing hard stool. Clinicians should provide education about normal stooling patterns in infants and manage constipation when it arises. There is insufficient evidence to routinely recommend use of a probiotic or hydrolyzed formula as first-line treatments of constipation in infants; however, in infants who do not respond to laxative therapy, a 2- to 4-week trial of a hypoallergenic formula (without cow’s milk protein) may be considered. For breastfed infants, a maternal avoidance diet of cow’s milk protein could alternatively be considered. It is advised for families to avoid or limit rectal manipulations to encourage regular bowel movements in infants; this can be associated with more problems like fissures, pain, and worsening symptoms.

Toilet Training
Constipation occurs more frequently in children who are toilet training. Painful stooling can lead to irritability or anxiety in children and increased reluctance to use the toilet. Clinicians should explain to parents that the development of continence of urine and of stool often does not happen simultaneously, and fecal incontinence occurs from involuntary overflow of stool and not from voluntary defiance. Clinicians can instruct parents to:
  • Ensure easy access to the potty or toilet, which should be comfortable getting on, off, and while sitting.
  • Provide supportive seating. The child should be able to rest his or her feet on a stool or the floor. Handles can provide additional support.
  • Provide adequate time to pass stool. Many children will have better success with passing stool if they regularly take advantage of the gastro-colic reflex after meals.
  • Gently encourage efforts to use the potty. Avoid reprimanding or shaming children when they have accidents. Use of small rewards like stickers can be helpful. Keeping a stool diary can be motivating as well as informative.
Older Children
Older children and adolescents may develop constipation when they attend school or are away from home. Many children feel anxious or embarrassed about using unfamiliar bathrooms to pass stool. In school, limited time and access to the bathroom make it harder to relax and pass stool. Inattentive or oppositional behaviors also can contribute to constipation. This can result in the painful and retentive cycle of constipation described above. This is often detected when the internal anal sphincter loses sensitivity, and encopresis occurs. Parents can help children in this situation by discussing and planning ahead for bowel movements outside the home and normalizing bodily functions to reduce any shame the child feels about stooling.

Setting a schedule to sit on the toilet for 5-10 minutes after meals, and possibly after school, may help children form good bowel habits. This time should be relaxed and not rushed. The child should be able to sit comfortably on the toilet with feet on a stool to facilitate good positioning with knees up. Blowing into a straw to inflate a balloon on the end or holding the knees or pillow are good ways to encourage proper Valsalva breathing techniques during active pushing. Boys may benefit from sitting to pee, providing an opportunity to pass stool at the same time. Keeping a bowel diary and using incentives to reward compliance with the stool schedule may be motivating to older children as well as for younger kids who are potty training. These techniques help children with constipation and also can be used for treatment of functional non-retentive fecal incontinence. [Koppen: 2016]

Prevention of Constipation
Although there is little supporting evidence, commonly given advice is to ensure healthy eating habits and diet, regular exercise, adequate fluid and fiber intake, and relaxed toileting, particularly after larger meals. Ensure that children and youth with neurologic impairment or tube feeding obtain adequate fiber and water intake. [Romano: 2017]

Fiber: A healthy diet helps ensure adequate nutrition and fiber intake and may help prevent constipation. A healthy diet includes at least 5 servings of fruits and vegetables daily in addition to peas, nuts, beans, and fiber-rich cereals and breads. Examples of particularly high-fiber foods include apples, pears, prunes, apricots, plums, raisins, raw tomatoes, peas, beans, broccoli, and sweet potatoes. Low-fiber or constipating foods include rice, cooked carrots, dairy products, bananas, and cereals or breads that are not high in fiber. [Healthy: 2017] MyPlate (USDA) offers personalized eating plans for families and interactive tools to help plan and assess food choices. Refer families to How to Get Your Child to Eat More Fruits & Veggies (AAP) for practical suggestions.

Traditionally, recommended daily grams of dietary fiber can be estimated using the child’s age plus 5-10; however, newer U.S. dietary guidelines advise higher fiber intake of 14g of fiber for every 1,000 calories in the diet. The following summarizes fiber intake goals for children and young adults based on the recommended high fiber goal: [U.S.: 2020]
  • Males
    • Age 2-3 years – 14 g
    • Age 4-8 years – 20 g
    • Age 9-13 years – 25 g
    • Age 14-18 years – 31 g
    • Age 19-30 years – 34 g
  • Females
    • Age 2-3 years – 14 g
    • Age 4-8 years – 17 g
    • Age 9-13 years – 22 g
    • Age 14-18 years – 25 g
    • Age 19-30 years – 28 g

For children >1 year old who are formula dependent, prescribe a formula with fiber unless it is not available or tolerated. More information about over-the-counter fiber supplements can be found below, toward the end of the Pharmacy & Medications section.

Scheduled Meals: Grazing, particularly on low-fiber foods, may increase the risk of constipation because it 1) decreases the size of regular meals and the resulting bolus of food that should propel stool through the gut and 2) reduces the gastro-colic reflex.

Water Intake: In the US, there are no commonly accepted recommendations for daily water intake for children. [Healthy: 2016] An Australian resource recommends 1.2-1.5 liters (around 5-6 cups) daily of water for children ages 4-13. [HealthyKids: 2015] Some clinicians use the Holliday-Segar method to estimate daily fluid requirements for a child: [Meyers: 2009] Fluid intake prescriptions for tube-fed children should include both the needed total liquid nutrition volume, total calories needed per day, plus additional free water to meet daily fluid requirements.

Holliday-Segar method for calculating daily fluid requirements:
  • 100 ml/kg for the 1st 10 kg of weight
  • 50 ml/kg for the 2nd 10 kg of weight
  • 20 ml/kg for the remaining weight
Holliday-Segar adaptation to calculate hourly maintenance fluids (useful for kids who are on continuous tube feeds):
  • 100 ml/kg/24-hours - 4 ml/kg/hr for the 1st 10 kg
  • 50 ml/kg/24-hours - 2 ml/kg/hr for the 2nd 10 kg
  • 20 ml/kg/24-hours - 1 ml/kg/hr for the remainder

Exercise: Recommend that children exercise daily for at least an hour. While there is a lack of high-quality evidence about using exercise as treatment for constipation, children who exercise regularly are at decreased risk for constipation. [Koppen: 2015] For children with restricted mobility, encourage time spent in upright positioning, such as in a stander or walker; there is very limited evidence that this positioning, which uses gravity, may help decrease pain associated with passing stools in children with cerebral palsy. [Rivi: 2014]

Relaxation: Discuss the benefits of relaxation. Ensure that children have regular, unrushed time on the toilet, ideally at least 5 minutes after meals. [Koppen: 2015] Increasing fluid intake leads to increased urination, which can help with anal relaxation. Sitting in a warm tub may be helpful, too. Deep breathing and conscious relaxation of the muscles involved in stool elimination can also help a child to relax; however, there is not sufficient evidence to recommend using biofeedback or behavioral therapies for routine treatment of children with functional constipation. [Tabbers: 2014]

Further information for clinicians: Complications of Constipation
Constipation, particularly chronic, can lead to pain, rectal fissures, rectal prolapse, hemorrhoids, encopresis, enuresis, urinary tract infections, ureteral obstruction, rectal ulcer (solitary), bacterial overgrowth, malabsorption, protein-losing enteropathy, and psychosocial disturbances.

Specialty Collaborations & Other Services

General Counseling Services (see UT providers [389])

A referral may be helpful to assist with behavioral concerns, non-pharmaceutical management of chronic pain, and anxiety, which may be contributing to constipation.

Pharmacy & Medications

In addition to dietary and lifestyle changes, over-the-counter and prescription laxatives can prevent and relieve constipation. Laxatives work by softening the stool and helping it to move more quickly through the intestine. Types of laxatives and dosing guidelines by age for clean-out and treatment are described below. Different laxative types include bulking agents (fiber), lubricating and emollient agents, osmotic and hyperosmolar agents, stimulating agents, and combined agents. Stimulant laxatives are not recommended for long-term use; however, when necessary, longer-term use of polyethylene glycol, mineral oil, magnesium hydroxide, and lactulose may be considered.  [Borowitz: 2016]

Based on current guidelines, the most highly recommended medications for maintenance therapy for functional constipation are polyethylene glycol and lactulose, in that order. Milk of magnesia, mineral oil, and stimulant laxatives can be added or used as second-line therapies. [Tabbers: 2014] However, the data supporting use of laxatives other than PEG are not as clear; a 2016 Cochrane review cited limited evidence for use of mineral oil or lactulose as second-line treatments to PEG. Maintenance therapy should be continued for several months and then gradually discontinued as tolerated. [Tabbers: 2014] Many experts advise consistent use of medications to achieve 1-2 mushy stools daily for at least 6, and sometimes up to 18 months, to permit the cycle of fear and pain from defecation to fully resolve. There is not sufficient evidence to support the widespread myth that laxatives cause physical dependency; although, constipation may recur in some people once the laxative is discontinued. In this situation, parents may need reassurance that treatment of chronic constipation is important to the child’s long-term health, particularly if there is a history of encopresis or slow motility.

A bowel clean-out may be indicated at the onset of treatment and periodically if a child tends to become intermittently “backed up.” Because the goal of a bowel clean-out for treatment of constipation is to stimulate motility and soften stool already within the digestive tract, stools do not need to reach a clear liquid consistency (in contrast to bowel clean-outs prior to colonoscopy).

Oral Iso-Osmotic Laxatives
Osmotic laxatives cause the intestinal tract to hold more fluid. Side effects may include gas, bloating, diarrhea, nausea, cramping, and thirst.

Polyethylene Glycol 3350 (e.g., PEG 3350, MiraLAX, GlycoLax) This is considered first-line treatment for pediatric constipation. It is iso-osmotic in maintenance doses, so it does not cause electrolyte abnormalities, but in clean-out doses is osmotic. Polyethylene Glycol (PEG) 3350 over-the-counter oral laxative (MiraLAX) has been added to the Potential Signals of Serious Risks List (FDA) for possible neuropsychiatric adverse effects; however, the FDA decided that no action is necessary at this time based on available information.
  • For clean-out of fecal impaction phase: 1-1.5 g/kg/day x 3-6 days, maximum 100 g/day
  • For maintenance phase: 0.2-0.8 g/kg/day (can be divided in 1-3 doses), maximum 17 g/day, often continued for several months
  • H2O ratio: 1 teaspoon to 2.5 oz. liquid; 17 g to 4-8 oz. liquid or 5 g = 1 teaspoon
    • 17 g = 1 capful = 1 heaping tablespoon
    • Do not count the PEG fluid volume in the child’s total daily maintenance fluid volume.
    • Avoid mixing with fat-containing liquids (like milk or formula) or in foods.
    • Works best if consumed within 20 minutes.
Lactulose (e.g., Enulose, Kristalose) - a synthetic sugar. This is considered first-line treatment for pediatric constipation after PEG 3350. It can cause flatulence and abdominal cramps.
  • Liquid (10 g/15 mL sol) or packets: 1-2 g/kg 1-2 times daily, max 40 g, in divided doses [Tabbers: 2014]; or 1-3 mL/kg/day of the 70% solution.
Magnesium hydroxide (e.g., Phillips Milk of Magnesia, PediaLax chewables, Dulcolax soft chews) - a saline laxative. Can cause hypermagnesemia and hypophosphatemia; check labs every 3-6 months. This is considered second-line therapy for constipation.
  • Phillips Milk of Magnesia original strength 400 mg/5 mL suspension  [Tabbers: 2014]
    • 2-5 years: 0.4-0.12 g/day or 5-15 mL/day in 1-2 divided doses
    • 6-11 years: 1.2-2.4 g/day or 15-30 mL/day in 1-2 divided doses
    • ≥12 years: 2.4-4.8 g/day or 30-60 mL/day in 1-2 divided doses 
  • PediaLax chewables
    • 2-5 years: 1-3 tablets
    • 6-11 years: 3-6 tablets
  • Dulcolax soft chews 1200 mg saline laxative (containing 500 mg magnesium). Take with 8 oz of liquid.
    • 6-12 years: 1-2 chews/day (can be taken once or divided)
    • ≥12 years: 2-4 chews/day (can be taken once or divided)

Magnesium citrate (e.g., Citroma, GoodSense) - a saline laxative. Can cause hypermagnesemia and hypophosphatemia; check labs every 3-6 months.
  • Citroma or GoodSense (1.75 g/30 mL) solution
    • 2-6 years: 3.5-5.25 mg (60-90 mL) daily
    • 6-12 years: 5.25-12.25 mg (90-210 mL) daily
    • >12 years: 12.25- 17.5 mg (195-300 mL) in single or divided doses
  • Citroma or GoodSense 100 mg tablets
    • >12 years: 200-400 mg (2-4 tablets) in single or divided doses

Magnesium also comes in a variety of other formulations, doses, and flavors.

Sorbitol (70% oral solution) - a sugar alcohol derived from fruit. Can cause hypermagnesemia and hypophosphatemia, flatulence, abdominal pain, and cramping.
  • 2-11 years: 2 mL/kg used once
  • >=12 years: 0-150 mL used once

Lubricant Laxatives
This type of laxative surrounds the outside of the stool with a slippery coating to enable smoother passage of stool and to keep water in the stool.

Mineral oil (e.g., Kondremol) [Tabbers: 2014] - This is considered second-line therapy for constipation. Avoid use in ages less than 2 due to risk of oil aspiration. Can mix in pudding or yogurt to decrease risk of aspiration.
  • 2-11 years: 30-60 mL daily
  • ≥12 years: 60-150 mL of plain mineral oil daily given as a single dose

Oral Stool Softeners
This type of laxative helps mix moisture into the stool to make it softer and reduce straining. Stool softeners do not trigger more frequent stool passage.

Sodium docusate (e.g., Colace, PediaLax Liquid Stool Softener). Requires a full-fat diet.
  • In liquid (50 mg/15 mL), syrup (60 mg/15 mL), or capsules (50, 100, 240, and 250 mg)
    • 2-11 years: 50-150 mg/day (single or divided)
    • ≥12 years: 50-360 mg/day (single or divided)
  • PediaLax [Tabbers: 2014]
    • 2-11 years: 1-3 tablespoons mixed with milk or juice
Oral Stimulant Laxatives
The harshest type of laxatives, stimulant laxatives are considered second-line therapy for constipation. Causes increased contractions of the gut to help move stool out within several hours. These are most often used to facilitate a clean-out. Use should be limited to a few days at most. Stimulated bowels feel crampy; encourage children to sit on the toilet when these cramps occur.

Senna/sennosides (e.g., ExLax, Little Tummies, Senokot) - in tablets (8.6 mg, 15 mg, and 25 mg doses), chewables (15 mg tablets), liquid and syrup (8.8 mg/5 mL)  [Tabbers: 2014]
  • 2-5 years: 2.5-5 mg/1-2 times daily
  • 6-12 years: 7.5-10 mg/day
  • >12 years: 15-20 mg/day
Senna pod extract (e.g., Fletchers) (167 mg/5 mL) (Dosing is not equivalent to other senna products.)
  • 2-5 years: 167-333 mg (5-10 mL) daily
  • 6-15 years: 333-500 mg (10-15 mL) daily or divided
Senna leaf extract  [Tabbers: 2014]
  • 2-6 years: 166.5-666 mg/day
  • 6-12 years: 333-999 mg/day
Bisacodyl (e.g., Biscolax, Dulcolax, Correctol in 5 mg tablets) [Tabbers: 2014]
  • 3-10 years: 5 mg/day
  • >10 years: 5-10 mg/day
Rectal Suppositories
These help evacuate the rectum by coating the stool and making it slippery. Stool typically is evacuated within an hour. Suppositories are not routinely advised for daily use.

Glycerin (e.g., Pedia-Lax, Fleets) - solid suppository in 1, 1.2, 2, and 2.8 mg sizes or liquid suppository (i.e., liquid delivered via rectal applicator)
  • Solid suppository
    • <4 months: 0.5 mg (1/2 pediatric suppository)
    • 4 months--5 years: 1 mg (1 pediatric suppository)
    • 6 years-adolescence: 2 mg (1 adult suppository)
  • Pedia-Lax liquid glycerin suppository (2.8 mg/2.25 mL bottle)
    • 2-5 years: 1 suppository given rectally x 1 via rectal applicator
Bisacodyl (e.g., Biscolax 10 mg suppository) [Tabbers: 2014]
  • 1-2 years: 1/2 suppository
  • 2-11 years: 1/2-1 suppository
  • ≥12 years: 1 suppository
Enemas
Enemas flush out the rectum and act more quickly than oral laxatives. Side effects can include incomplete evacuation of the fluid, which can lead to discomfort, distension, or electrolyte imbalances. There are other do-it-yourself and commercial enemas, but due to the risks, only 2 selected osmotic enemas are presented here.

Saline enema (e.g., Pedia-Lax, Fleet Saline) - The FDA announced in 2014 that using these more than once daily can result in serious harm to the kidneys and should NEVER be given to children under 2 years of age. [Tabbers: 2014] [U.S.: 2016]
  • Pedia-Lax (monobasic sodium phosphate 9.5 g and dibasic sodium phosphate 3.5 g/66 mL bottle)
    • 2-4 years: 1/2 bottle
    • 5-11 years: 1 bottle rectally x 1
  • Adult saline enema (Fleets - 19 g monobasic sodium phosphate monohydrate and 7 g dibasic sodium phosphate heptahydrate/188 mL bottle)
    • ≥12 years: 1 bottle
Mineral oil enema [Tabbers: 2014]
  • 2-11 years: 30-60 mL daily
  • ≥12 years: 60-150 mL daily
Sodium docusate enema (e.g., DocuSol Kids-100 mg/5 mL, DocuSol Mini and Enemeez Mini-283 mg/~5 mL tube)
  • 2-12 years: 100 mg (1 DocuSol Kids tube)
  • ≥12 years: 283 mg (1 DocuSol or Enemeez Mini tube)
  • Alternative dosing  [Tabbers: 2014]
    • <6 years: 60 mL daily
    • >6 years: 120 mL daily
Bisacodyl enema (e.g., Fleet Bisacodyl (10 mg/37 mL container) [Tabbers: 2014]
  • 2-10 years: 5 mg (1/2 enema) daily
  • >10 years: 5-10 mg (1/2-1 enema) daily
Other Oral Medications
Other oral medications are occasionally used to treat adult chronic constipation, such as lubiprostone (Amitiza), linaclotide (Linzess, Constella), prucalopride (Reselor, Motegrity), tegaserod (Zelnorm), and alvimopan (Entereg). These medications SHOULD NOT be used in the primary care management of pediatric constipation.

Fiber/Oral Bulk-Forming Laxatives

Fiber supplements have not been demonstrated to be effective in the treatment of pediatric constipation. Limited evidence shows that additional fiber improves constipation and may help in prevention. [Tabbers: 2014] Fiber is the non-digestible carbohydrate portion of many foods. Both soluble and insoluble fibers are important to digestive tract health. 

Insoluble fiber: Helps “bulk” the stools and promotes normal contractions and motility so stools pass more quickly through the GI tract. Insoluble fiber food sources include wheat bran, whole grains (cereal, pasta, and bread), seeds, nuts, leafy greens, broccoli, and the skins of many fruits and root vegetables. Other sources are as follows:

Soluble fiber: Slows digestion by attracting water and forming a gel, which allows time in the GI tract for nutrients to be absorbed, helps regulate blood sugar, and potentially reduces LDL cholesterol. In general, soluble fiber is less helpful than insoluble fiber in fighting constipation. Soluble fiber food sources include oatmeal, lentils, seeds and beans, psyllium, chicory and inulin, and certain berries. Other sources are as follows:

Over-the-counter fiber supplements: These include but are not limited to:
  • Methylcellulose (Citrucel) contains insoluble semi-synthetic fiber. It is non-fermentable, so not as likely as fermentable fiber to produce gas.
  • Polycarbophil (FiberCon) contains insoluble synthetic fiber and is also non-fermentable.
  • Fiber gummies can contain either or both soluble and insoluble types of fiber.
  • Wheat dextrin (Benefiber) contains soluble fiber, which is fermentable in the gut.
  • Psyllium (Metamucil) contains about 70% soluble fiber and 30% insoluble fiber. It is partially fermentable and may cause gas.
  • Barley malt extract (Maltsupex) contains soluble fiber.
  • Guar gum fiber (Reliefiber) is partially hydrolyzed soluble fiber extracted from guar beans and is less fermentable in the gut.
Use of fiber supplements can lead to bloating, gas, cramping, and constipation, particularly if not taken with adequate water. Be aware that fiber gummies often contain Inulin which can cause excessive gas. Side effects are reduced or eliminated by starting with small amounts and gradually working up to the dose and frequency goal. As a guideline, increase the dose gradually to 1/2 or 1 rounded teaspoon, packet, or wafer in 4 oz. of water 1-3 times per day. [Drugs.com: 2008] Long-term use of fiber is fine. If fiber is not tolerated, or not effective due to underlying medical conditions, then other medications can be considered. For more information about adding fiber to the diet, see Dietary Fiber (IFFGD) and Kids Need Fiber: Here’s Why and How (AAP).

Specialty Collaborations & Other Services

Pharmacies / Prescriptions (see UT providers [31])

Refer for questions about medication use and administration.

Complementary & Alternative Medicine

The following therapies may have some benefit as adjuncts but are usually not effective in managing constipation for the majority of pediatric patients.

Acupuncture: Acupuncture is gaining some supporting evidence for use in adults with constipation, and there is emerging evidence for biofeedback use in adults with dys-synergic defecation. [Broide: 2001] [Rao: 2015] However, acupuncture is not currently recommended for routine treatment of childhood constipation due to lack of supporting evidence in this population.

Behavioral therapy: While behavioral therapy lacks evidence to treat functional constipation, behavioral supports can encourage healthy toileting practices and can be used to address non-retentive fecal incontinence.

Biofeedback: Biofeedback, used to guide pelvic floor contractions and relaxation, is gaining some supporting evidence for use in children with dyssynergic defecation. [Jarzebicka: 2016]

Dairy avoidance: A 2- to 4-week trial of avoidance of cow’s milk protein (CMP) may be indicated in the child with intractable constipation that does not respond to laxatives. [Tabbers: 2014] Since CMP intolerance or allergy is not typically IgE mediated, blood levels, patch, or skin prick test are not routinely recommended for diagnosis. [Vandenplas: 2015] For breastfed babies, a maternal elimination diet may be trialed.

Electrical stimulation: Interferential electrical stimulation has some evidence for use in treatment of functional constipation in children, in conjunction with pelvic floor muscle therapy.

Fecal microbiota transplantation (FMT): FMT is undergoing study as a possible treatment for constipation in children and adults. [Avelar: 2020] It is not an evidence-based treatment for pediatric functional constipation at this time.

Home remedies: Current clinical practice guidelines do NOT recommend use of natural remedies or alternative therapies for treatment of functional constipation in large part because they often lack safety studies and may be unhealthy or dangerous, especially in high doses. Be aware of some remedies that caregivers may be using:
  • Lemon juice to stimulate contractility.
  • Molasses by mouth can have stimulating effects but is not currently recommended for routine treatment of constipation, although one study demonstrated similar effectiveness to polyethylene glycol 3350. (A hospital in Utah no longer performs or recommends milk and molasses enemas due to a sentinel event.)
  • Aloe is thought to help with occasional constipation, yet it can be unsafe at high doses and therefore should not be used for routine treatment of constipation. [WebMD: 2015]
Probiotics: Probiotics generally do not have sufficient evidence to be used in treatment or prevention of chronic constipation; however, they are beneficial to overall intestinal health. [Thomas: 2010] They may increase stool frequency in children, but more study is needed.

Prebiotics: These are non-digestible food ingredients that help propagate healthy gut bacteria. All prebiotics are fiber, but not all fibers are prebiotic. Examples of prebiotics include inulin, wheat dextrin, and polydextrose. [Slavin: 2013]

Ask the Specialist

When do children need admission to the hospital for constipation clean-outs?

With persistence of the parents and detailed education and encouragement from the primary care provider, almost all children with constipation, including children with developmental difficulties, can do colon or bowel clean-outs at home. Reasons to send a patient to the emergency room may include suspected bowel obstruction (bilious emesis, signs of obstruction on abdominal X-ray, severe abdominal distention) or inability to tolerate any kind of oral intake.

When do primary care physicians need to refer children with constipation to the pediatric gastroenterology clinic?

Most children with constipation can be successfully managed by primary care physicians. Reasons to refer to the pediatric gastroenterology clinic include presence of alarming signs or symptoms suggestive of organic disease, relapse of symptoms after initial successful treatment, and no improvement after appropriate treatment.

Is a “stool ball” an indication for manual digital evacuation?

The only true indication for manual digital evacuation is bowel obstruction or suspected bowel obstruction due to impacted stool. Most fecal impactions can be disimpacted with oral or rectal medication, such as an enema. A stool ball may be present in 85% of children in the morning and is not an indication for manual digital evacuation.

Resources for Clinicians

On the Web

Differential Diagnosis of Constipation in Children (AAFP)
This article reviews assessment and management of constipation in children. Table 4 lists recommended diagnostic evaluation for conditions that may be constipation in children; American Academy of Family Physicians.

Pediatric Constipation (Project ECHO Webinar)
In this 49-minute webinar video, Dr. Raza Patel, gastroenterologist at University of Utah Health, discusses constipation in newborns, infants, and children in developing stages. He provides resources and treatment methods for providers and parents. Presented on 1/20/2021.

PedsGI.Net
Raza Ali Patel MD, MPH, a board-certified Pediatric Gastroenterologist at the University of Utah/Primary Children’s Hospital, developed this web-page to help patients and families and to act as a resource to others around the world with common pediatric gastroenterology issues. The site offers quality medical information about constipation, eosinophilic esophagitis, transnasal endoscopy, and colonoscopy.

Helpful Articles

Benninga MA, Tabbers MM, van Rijn RR.
How to use a plain abdominal radiograph in children with functional defecation disorders.
Arch Dis Child Educ Pract Ed. 2016;101(4):187-93. PubMed abstract
This review describes and evaluates the value of different existing scoring methods to assess faecal loading on an abdominal radiograph with or without the use of radio-opaque markers, to measure colonic transit time, in the diagnosis of these defecation-related FGIDs.

Rajindrajith S, Devanarayana NM, Thapar N, Benninga MA.
Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management.
J Pediatr Gastroenterol Nutr. 2021. PubMed abstract
Functional fecal incontinence (FI) comprises constipation-associated fecal incontinence and nonretentive fecal incontinence. Although conventional interventions such as toilet training and laxatives successfully treat most children with constipation associated FI, children with nonretentive fecal incontinence need more psychologically based therapeutic options. Intrasphincteric injection of botulinum toxin, transanal irrigation and, in select cases, surgical interventions have been used in more resistant children with constipation associated FI.; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology.

Romano C, van Wynckel M, Hulst J, Broekaert I, Bronsky J, Dall'Oglio L, Mis NF, Hojsak I, Orel R, Papadopoulou A, Schaeppi M, Thapar N, Wilschanski M, Sullivan P, Gottrand F.
European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment.
J Pediatr Gastroenterol Nutr. 2017;65(2):242-264. PubMed abstract
With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment.

Southwell BR.
Treatment of childhood constipation: a synthesis of systematic reviews and meta-analyses.
Expert Rev Gastroenterol Hepatol. 2020;14(3):163-174. PubMed abstract
This review covers meta-analyses and evidence for treatment of paediatric constipation since 2016 and new emerging treatments.

Clinical Tools

Assessment Tools/Scales

Bristol Stool Form Scale (PDF Document 383 KB)
Images of 7 stool types, created to facilitate better communication among families and clinicians about bowel movements; developed by the Bristol Royal Infirmary.

Chronic Constipation Evaluation Tool (PDF Document 84 KB)
Provides a format for evaluation of chronic constipation in children. Can be used as a note in a paper chart, or reformatted for electronic medical records.

Questionnaires/Diaries/Data Tools

Stool Diary Using Bristol Stool Form Scale (NIH) (PDF Document 147 KB)
Printable record of stool habits for 1 week; originally from Lewis SJ, Heaton KW, Scandinavian Journal of Gastroenterology - reproduced by the National Institutes of Health.

Food Record (University of Rochester) (PDF Document 151 KB)
A 3-day food record with instructions for parents.

Poo Keeper
Free app for smartphones or tablets, available on Apple and Google Play, is used to record stool type and consistency and keep a bowel habits log that can be shared with a physician. Offers in-app purchases.

Patient Education & Instructions

Complete Constipation Care Package (GIKids) (PDF Document 178 KB)
14-page packet of printable patient education materials from the American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Includes Constipation (pgs 1-2), Constipation and Fecal Soiling with cleanout and maintenance therapy (pgs 3-5), Nutrition for Constipation in the First 12 Months (pg 6), Fluid and Fiber (pgs 7-9), Water Tracker (pg 10), Toilet Training Tips (pgs 11-13), and Bowel Management Tool (pg 14).

Complete Constipation Care Package - Spanish Version (PDF Document 2.0 MB)

Complete Constipation Care Package - French Version (PDF Document 2.0 MB)

Constipation in Children: Understanding and Treating This Common Problem (Video)
An 8-minute video that helps parents and other caregivers understand constipation and what can be done to remedy it. Explains bowel clean-outs, maintenance therapy, and the brain-gut connection; made by experts from the Pediatric Gastroenterology Clinic at Primary Children’s Hospital.

The Poo in You - Constipation and Encopresis Video (Children's Hospital Colorado)
Excellent 5-minute video about why soiling accidents occur and what can be done to make them stop happening. Includes simple information about the digestive process, role of colon, and medicines that may help with constipation and resulting encopresis.

La Popó Dentro De Ti (video)

The Poo In You - Deutsch /German version

Let’s Talk About Constipation and Home Bowel Program (Intermountain Healthcare) (PDF Document)
4-page printable handout explaining childhood constipation and home care, with scannable link to video.

Let's Talk About... Rectal Suppository (Spanish & English)
Two-page handout for caregivers about rectal suppositories for children; Intermountain Primary Children's Hospital.

Hablemos Acercos De...Supositorio Rectal (PDF Document)

Let's Talk About... Enemas, Small Volume (Spanish & English)
Handout for caregivers on how to give small volume enemas to children; Intermountain Primary Children's Hospital.

Hablemos Acercos De...Enema, Volumen Pequeño (PDF Document)

Let's Talk About... Enemas, Large-Volume (Spanish & English) (PDF Document)
Handout for caregivers on how to give large-volume enemas of saline, glycerin, castile soap, or phosphate solution to children; Intermountain Primary Children's Hospital.

Hablemos Acercos De...Enema, Gran Volumen (PDF Document)

Resources for Patients & Families

Information on the Web

GIKids (NASPGHAN)
GIKids provides children and families with resources and easy-to-understand information on the diagnosis and management of pediatric digestive disorders including: Celiac disease, Constipation, Eosinophilic esophagitis, GERD & Reflux, Inflammatory Bowel Disease, plus nutrition, tests, and procedures; North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN).

Constipation in Children (AAP)
Learn how to know if your child is constipated and, if so, what to do about it; on HealthyChildren.org, sponsored by the American Academy of Pediatrics.

About Kids GI Health (IFFGD)
Reliable digestive health knowledge, support, and assistance about functional gastrointestinal and motility disorders in children and adults; International Foundation for Functional Gastrointestinal Disorders.

Baby's First Days: Bowel Movements & Urination (AAP)
Important points about first bowel movements on HealthyChildren.org; American Academy of Pediatrics.

Dietary Fiber (IFFGD)
Information about different kinds of fiber, how to incorporate fiber into the diet gradually, and serving sizes to help prevent constipation; International Foundation for Functional Gastrointestinal Disorders.

Q & A Disorders of Gut-Brain Interaction (DGBI) and Pediatric Populations
Videos of experts discussed DGBI in children. The Rome Foundation is an independent not-for-profit organization dedicated to supporting the creation of scientific data and educational information to assist in diagnosing and treating DGBIs, formerly called Functional Gastrointestinal Disorders (FGIDs).

Studies/Registries

Pediatric Constipation (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Services for Patients & Families in Utah (UT)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: January 2017; last update/revision: June 2021
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewer: Raza Patel, MD
Authoring history
2017: first version: Jennifer Goldman-Luthy, MD, MRP, FAAPSA; Ramakrishna Mutyala, MDR; Mark Deneau, MDR; Chuck Norlin, MDR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Bibliography

Avelar Rodriguez D, Popov J, Ratcliffe EM, Toro Monjaraz EM.
Functional Constipation and the Gut Microbiome in Children: Preclinical and Clinical Evidence.
Front Pediatr. 2020;8:595531. PubMed abstract / Full Text
In this review, we provide an overview of preclinical and clinical studies that focus on the potential mechanisms through which the gut microbiome might contribute to the clinical presentation of functional constipation in pediatrics.

Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S.
Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.
Gastroenterology. 2016. PubMed abstract

Benninga MA, Tabbers MM, van Rijn RR.
How to use a plain abdominal radiograph in children with functional defecation disorders.
Arch Dis Child Educ Pract Ed. 2016;101(4):187-93. PubMed abstract
This review describes and evaluates the value of different existing scoring methods to assess faecal loading on an abdominal radiograph with or without the use of radio-opaque markers, to measure colonic transit time, in the diagnosis of these defecation-related FGIDs.

Borowitz SM.
Pediatric Constipation Medication.
Medscape; (2016) http://emedicine.medscape.com/article/928185-medication. Accessed on June 2021.
Written by medical experts, information about medications used to treat constipation in children. Medications include osmotic laxatives, lubricants, stimulant laxatives, stool softeners, and stool softeners in combination with stimulants. Sign in required.

Broide E, Pintov S, Portnoy S, Barg J, Klinowski E, Scapa E.
Effectiveness of acupuncture for treatment of childhood constipation.
Dig Dis Sci. 2001;46(6):1270-5. PubMed abstract

Carlisle BJ, Craft G, Harmon JP, Ilkevitch A, Nicoghosian J, Sheyner I, Stewart JT.
PEG and Thickeners: A Critical Interaction Between Polyethylene Glycol Laxative and Starch-Based Thickeners.
J Am Med Dir Assoc. 2016;17(9):860-1. PubMed abstract

Drugs.com.
Bulk-Forming Laxatives.
Drugs.com; (2008) http://www.drugs.com/monograph/bulk-forming-laxatives.html. Accessed on June 2021.
Fiber laxatives with doses and warnings.

Gordon M, MacDonald JK, Parker CE, Akobeng AK, Thomas AG.
Osmotic and stimulant laxatives for the management of childhood constipation.
Cochrane Database Syst Rev. 2016(8):CD009118. PubMed abstract

Healthy Children Magazine.
Constipation.
American Academy of Pediatrics; (2017) http://www.healthychildren.org/English/health-issues/conditions/abdomi.... Accessed on June 2021.
How to know if your child is constipated and what to do.

Healthy Children Magazine.
Childhood Nutrition.
American Academy of Pediatrics; (2016) http://www.healthychildren.org/English/healthy-living/nutrition/Pages/.... Accessed on 8/30/2016.
Information about what to eat and how much; healthychildren.org is from the American Academy of Pediatrics.

HealthyKids.
Choose Water as a Drink.
Department of Health - New South Wales (NSW); (2015) http://www.healthykids.nsw.gov.au/downloads/file/kidsteens/HealthyKids.... Accessed on June 2021.
How much water children should drink.

Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M.
Functional Disorders: Children and Adolescents.
Gastroenterology. 2016. PubMed abstract

International Foundation for Functional Gastrointestinal Disorders.
Stool Form Guide.
International Foundation for Functional Gastrointestinal Disorders; (2016) http://www.aboutconstipation.org/site/treatment/stool-form-guide. Accessed on 8/30/2016.
Bristol Stool Form Guide with types, images, and descriptions.

Jarzebicka D, Sieczkowska J, Dadalski M, Kierkus J, Ryzko J, Oracz G.
Evaluation of the effectiveness of biofeedback therapy for functional constipation in children.
Turk J Gastroenterol. 2016;27(5):433-438. PubMed abstract
The aim of this retrospective study was to evaluate the effectiveness of biofeedback therapy as assessed by clinical improvement as well as by changes in manometric parameters in children with constipation and pelvic floor dyssynergia (PFD).

Koppen IJ, Lammers LA, Benninga MA, Tabbers MM.
Management of Functional Constipation in Children: Therapy in Practice.
Paediatr Drugs. 2015;Oct. PubMed abstract / Full Text

Koppen IJ, von Gontard A, Chase J, Cooper CS, Rittig CS, Bauer SB, Homsy Y, Yang SS, Benninga MA.
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Koppen IJN, Vriesman MH, Saps M, Rajindrajith S, Shi X, van Etten-Jamaludin FS, Di Lorenzo C, Benninga MA, Tabbers MM.
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J Pediatr. 2018;198:121-130.e6. PubMed abstract
This study systematically reviewed the literature regarding the epidemiology of functional constipation and functional nonretentive fecal incontinence (FNRFI) in children. Secondary objectives were to assess the geographical, age, and sex distribution of functional constipation and FNRFI and to evaluate associated factors.

Levy J, Volpert D.
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Philips EM, Peeters B, Teeuw AH, Leenders AG, Boluyt N, Brilleslijper-Kater SN, Benninga MA.
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Rajindrajith S, Devanarayana NM, Thapar N, Benninga MA.
Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management.
J Pediatr Gastroenterol Nutr. 2021. PubMed abstract
Functional fecal incontinence (FI) comprises constipation-associated fecal incontinence and nonretentive fecal incontinence. Although conventional interventions such as toilet training and laxatives successfully treat most children with constipation associated FI, children with nonretentive fecal incontinence need more psychologically based therapeutic options. Intrasphincteric injection of botulinum toxin, transanal irrigation and, in select cases, surgical interventions have been used in more resistant children with constipation associated FI.; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology.

Rao SS, Benninga MA, Bharucha AE, Chiarioni G, Di Lorenzo C, Whitehead WE.
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Rivi E1, Filippi M, Fornasari E, Mascia MT, Ferrari A, Costi S.
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Romano C, van Wynckel M, Hulst J, Broekaert I, Bronsky J, Dall'Oglio L, Mis NF, Hojsak I, Orel R, Papadopoulou A, Schaeppi M, Thapar N, Wilschanski M, Sullivan P, Gottrand F.
European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment.
J Pediatr Gastroenterol Nutr. 2017;65(2):242-264. PubMed abstract
With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment.

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This review covers meta-analyses and evidence for treatment of paediatric constipation since 2016 and new emerging treatments.

Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA.
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Possible harm from exceeding recommended dose of over-the-counter sodium phosphate products to treat constipation.
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Vandenplas Y, Alarcon P, Alliet P, De Greef E, De Ronne N, Hoffman I, Van Winckel M, Hauser B.
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Childhood constipation: longitudinal follow-up beyond puberty.
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